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INTRODUCTION:
Several studies have demonstrated better outcomes for carotid endarterectomy (CEA) at high-volume hospitals and providers. However, only a few studies have reported on the impact of surgeons’ specialty and volume on the perioperative outcome of CEA.
METHODS:
This is a retrospective analysis of prospectively collected CEA data during a recent two-year period. Surgeons’ specialties were classified according to their Board specialties into: general surgeons (GS), cardiothoracic (CT), and vascular surgeons (VS). Surgeons’ annual volume was categorized into: low volume (<10 CEAs), medium volume (10-<30 CEAs), and high volume (≥30 CEAs). The primary outcome was 30-day perioperative stroke and/or death. Other perioperative complications were analyzed. Both univariate and multivariate analyses were done to predict the effect of specialty/volume and any other patient risk factors on stroke outcome.
RESULTS:
Nine hundred and fifty-three CEAs were performed by 24 surgeons: 122 by seven GS, 383 by 13 CT, and 448 by four VS. Patients’ demographics/clinical characteristics were similar between specialties, except the incidence of coronary artery disease, which was higher for CT (p<0.0001). The indications for CEA were symptomatic disease in 38% for VS, 31% for GS, and 23% for CT (p<0.0001). The perioperative stroke and death rates were 4.1%, 2.9%, and 1.3% for GS, CT, and VS, respectively (p=0.1263). A sub-group analysis showed that the perioperative stroke rates for symptomatic patients were 5.3%, 2.3%, and 2.3% (p=0.5112) and for asymptomatic patients were 3.6%, 3%, and 0.72% (p=0.0992) for GS, CT, and VS, respectively. Perioperative stroke rates were significantly higher for non-vascular surgeons (GS and CT combined) versus VS in asymptomatic patients (3.2% versus 0.72%, p=0.0333). Perioperative stroke/death was also significantly lower for high volume surgeons: 1.3% versus 4.1% and 4.3% for medium and low-volume surgeons (p=0.0194) (1.3% versus 4.15% for high versus low/medium combined, p=0.005, Figure). More CEAs were done for asymptomatic patients in the low/medium surgeons (78%) versus high volume surgeons (64%, p<0.0001) with a stroke rate of 4.6% for low/medium volume surgeons versus 0.51% for high volume surgeons (p=0.0005). A univariate logistic analysis showed that the odds ratio (OR) of having a perioperative stroke was 0.3 (95% confidence interval = 0.13-0.73, p=0.0079) for high-volume surgeons, 0.4 (p=0.0686) for VS, 0.2 (p=0.0004) when patching was used, and 2.6 (p=0.0521) for patients with preoperative renal insufficiency. A multivariate analysis showed that the OR of having a perioperative stroke for CT (versus VS group) was 1.8 (p=0.269), for GS 1.7 (p=0.407), low volume surgeons (versus high volume) 3.1 (p=0.073) medium volume surgeons 2.0 (p=0.197), and for patching 0.25 (p=0.013, Table).
CONCLUSIONS:
High-volume surgeons had significantly better perioperative stroke/death rates for CEA than low/medium-volume surgeons. Perioperative stroke/death rates were also higher for non-vascular surgeons, particularly in asymptomatic patients.

Multivariate Logistic Analysis for Perioperative Stroke for Specialty and Volume

Variable	Odds Ratio	95% Confidence Interval	p value
Specialty CT versus VS	1.8	0.64-4.98	0.269
GS versus VS	1.7	0.47-6.51	0.407
Preoperative renal insufficiency	2.4	0.89-6.25	0.083
Patching	0.2	0.07-0.62	0.005
Volume Low versus high	3.1	0.90-10.76	0.074
Medium versus high	2.0	0.70-5.76	0.197
Preoperative renal insufficiency	2.5	0.92-6.56	0.073
Patching	0.25	0.08-0.74	0.013